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Bishop Score
Wormer KC, Bauer A, Williford AE.

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Continuing Education Activity

In 1964, Edward Bishop set forth criteria for
elective induction of labor which included parity,
gestational age, fetal presentation, obstetric history,
and patient consent as well as a scoring system for
the cervix to help predict successful induction of
labor. This pelvic scoring system, widely known as
the Bishop score, is still an important determination
in the prediction of successful induction of labor.
The pelvic score can be ascertained in a patient at
the time of induction by a digital cervical exam to
determine if cervical ripening is necessary before
induction. This activity describes the Bishop score
criteria and highlights the role of the
interprofessional team in the management of a
patient at the end of her pregnancy.

Objectives:

Identify the criteria involved in the Bishop

score.
Describe the indications for use of the Bishop
score.
Review the clinical relevance of the Bishop
score.
Summarize the importance of the use of the
Bishop score in improving care coordination
among interprofessional team members to
improve outcomes in patients awaiting labor
and delivery.

Access free multiple choice questions on this topic.

Introduction
In 1964, Edward Bishop set forth criteria for
elective induction of labor which included parity,
gestational age, fetal presentation, obstetric history,
and patient consent as well as a scoring system for
the cervix to help predict successful induction of
labor. This pelvic scoring system, widely known as
the Bishop score, is still an important determination
in the prediction of successful induction of labor.
The pelvic score can be ascertained in a patient at
the time of induction by a digital cervical exam to
determine if cervical ripening is necessary before
induction.[1][2][3]

Anatomy and Physiology

The Bishop score reflects the normal changes the
cervix undergoes in parturition (the process of
childbirth). Extensive cervical remodeling is
needed for the cervix to dilate and pass a fetus
fully. While human parturition is not completely
understood, it is a complex system that involves
interactions between placental, fetal, and maternal
mechanisms. The nonpregnant cervix extracellular
matrix is primarily made up of tightly packed
collagen bundles. Gradually throughout the
pregnancy the composition of the cervix changes
with decreased collagen density and an increase in
hyaluronic acid and water content. In the days to
weeks before delivery, through a cascade of events,
inflammatory mediators increase the production of
prostaglandins. Prostaglandins invading the cervix
mediate the release of metalloproteases that break
down collagen and change the cervical
structure. Cervical softening and distention results
from these extracellular matrix compositional
changes, specifically, increased vascularity and
stromal and glandular hypertrophy, and are due in
part to an increase in collagen solubility.

Indications
The Bishop scoring system is based on a digital
cervical exam of a patient with a zero point
minimum and 13 point maximum. The scoring
system utilizes cervical dilation, position,
effacement, consistency of the cervix, and fetal
station. Cervical dilation, effacement, and station
are scored 0 to 3 points, while cervical position and
consistency are scored 0 to 2 points (see chart
below).[4][5][6]

Cervical dilation is the measure of how dilated

the cervix is in centimeters. This is performed
by estimating the average diameter of the
open cervix.
Effacement is the thinning or shortening of the
cervix expressed as a percentage of the whole
cervix. Zero percent effacement means the
cervix is a normal, pre-labor length. Fifty
percent effaced means the cervix is at half of
the expected length. If the cervix is 100%
effaced, it is paper thin.
The station is the position of the fetal head
relative to the ischial spines of the maternal
pelvis. The ischial spines are halfway between
the pelvic inlet and outlet. At zero station, the
fetal head is at the level of the ischial spines.
Above and below this level are divided into
thirds, by which station is denoted with
negative numbers above and positive numbers
below the zero station. As a fetal head makes
its descent, the station changes from -3, -2, -1,
0, +1, +2, +3. In 1989, the American College
of Obstetrics and Gynecology redefined
station from -5 to +5, using centimeters
instead of thirds as a measurement from the
ischial spines. The Bishop score, however,
uses the -3 to +3 system.
Position refers to the position of the cervix
relative to the fetal head and maternal pelvis.
The consistency of the cervix refers to the feel
of the cervix on the exam. A firm cervix has a
consistency similar to the tip of the nose,
while a soft cervix has a consistency similar to
the lips of the oral cavity.

A Bishop score of 8 or greater is considered to be

favorable for induction, or the chance of a vaginal
delivery with induction is similar to spontaneous
labor. A score of 6 or less is considered to be
unfavorable if an induction is indicated cervical
ripening agents may be utilized.

The most common modification to the Bishop score

is a simplified scoring system that just takes into
account dilation, effacement, and station (each
scored 0 to 3 points). In this shortened
modification, a score of more than 5
is considered favorable.

Contraindications
Avoid digital cervical exams in a patient with
placenta previa or before establishing a diagnosis of
preterm rupture of membranes.

Clinical Significance
Induction of labor is a commonplace obstetric
practice. Currently, more than 20% of pregnant
women in the United States deliver as a result of
labor. Predictors for success in induction include
many of the similar criteria Bishop set forth in the
1960s. While, originally, the Bishop score
was designed for multiparous patients, it applies to
nulliparous patients undergoing induction as well.
Increasing maternal parity is a strong indicator of
the likelihood of successful vaginal delivery and a
predictor of shorter length of labor. Fetal size,
gestational age, maternal age, provider patience,
and decision to induce versus expectantly manage
can be correlated to differing success rates.
Maternal body mass index can play a role as well,
with the increased length of labor and cesarean
delivery rates. The Bishop score is still widely in
use to determine whether or not a cervix is
“favorable” and to assess whether or not cervical
ripening is needed. While Bishop score has been
found to be useful for predicting vaginal delivery
with sensitivity around 75% (similar between the
full and modified scores) as well as a positive
predictive value 83% to 84%, it has poor specificity
and negative predictive value.

If a cervix is favorable, induction of labor is likely

to result in vaginal delivery, and any method of
induction tends to work well. In the scenario of a
favorable cervix, labor induction is normally
undertaken with oxytocin and/or amniotomy.

If a cervix is considered to be unfavorable, no

method is highly effective for induction so that
patient is a candidate for cervical ripening. Cervical
ripening is a process that helps prepare the cervix
for labor and can result in a more favorable cervix.
There are two main types of cervical ripening,
prostaglandin use and mechanical methods.
Prostaglandins are a medication that can be given
vaginally, buccally, or orally to a patient with an
unscarred uterus that can help the cervix progress to
a more favorable Bishop score in 12 to 24 hours.
Mechanical methods such as a balloon catheter and
hygroscopic dilators can be used as well.
Mechanical methods, such as a balloon catheter,
have shown to have similar outcomes to
prostaglandins. Mechanical methods can be used in
conjunction with prostaglandins in certain clinical
scenarios.

Enhancing Healthcare Team

Outcomes
The bishop score is still an important determination
in the prediction of successful induction of
labor. The pelvic score can be ascertained in a
patient at the time of induction by a digital cervical
exam to determine if cervical ripening is necessary
before induction. The score is often performed by a
labor and delivery nurse or an obstetrician.

Review Questions
Access free multiple choice questions on this
topic.
Comment on this article.

Figure
Bishop Scoring System. Contributed by
Kelly Wormer, MD

References
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Landy HJ, Reddy UM. Early preterm
preeclampsia outcomes by intended mode of
delivery. Am J Obstet Gynecol. 2019
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Equy V, Michy T, Hoffmann P. Obstetric
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5. Keulen JKJ, Bruinsma A, Kortekaas JC, van
Dillen J, van der Post JAM, de Miranda E.
Timing induction of labour at 41 or 42 weeks?
A closer look at time frames of comparison: A
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[PubMed]
6. Lajusticia H, Martínez-Domínguez SJ, Pérez-
Roncero GR, Chedraui P, Pérez-López FR.,
Health Outcomes and Systematic Analyses
(HOUSSAY) Project. Single versus double-
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Publication Details

Author Information and A!liations

Authors

Kelly C. Wormer1; Amelia Bauer2; Ann E. Williford3.

A!liations

1
UT HSC Nashville at St Thomas Midtown
2
University of Pikeville Kentucky College of Osteopathic
Medicine
3
University of Tennessee-Nashville

Publication History

Last Update: September 5, 2022.

Copyright
Copyright © 2022, StatPearls Publishing LLC.

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Publisher

StatPearls Publishing, Treasure Island (FL)

NLM Citation

Wormer KC, Bauer A, Williford AE. Bishop Score. [Updated

2022 Sep 5]. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2022 Jan-.